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Counseling Form
First Name
*
Last Name
*
Email Address
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Phone
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Address
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Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Full Name of Child Diagnosed with Cancer/LCH/HLH/Aplastic Anemia
*
Date of Birth
*
MM slash DD slash YYYY
Diagnosis / Type of Cancer
*
Date of Diagnosis
*
MM slash DD slash YYYY
My child is:
*
On Active Treatment
Has Completed Treatment
Deceased
Date of Death
MM slash DD slash YYYY
Name of family member for whom you are seeking therapy
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By submitting this form, I give CURE Childhood Cancer permission to provide my name, contact information, and limited health information regarding the child with cancer to the Providers providing counseling services. By submitting I am also stating that I have read and understand these Guidelines and the Disclaimer provided above.
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About CURE
History
About Childhood Cancer
Our Story
Named Funds
Alex Cawood’s Universe
Anna’s Angel Fund
Anna Charles Hollis Fund
Blackberry Smoke Fund
Carlos S. Alvarado, MD Pediatric Cancer Research Fund
Catie’s Fund
Creedlove Fund
Jack’s Fund
Team Alexa Fighting Back
The Sam Robb Fund
Trenton W. Kindred Research Fund
United for a CURE
Staff
Board of Directors
Young Professional Leadership Council
Fiscal Responsibility
Our Research
Precision Medicine
Fellows
Current Research
Scientific Advisory Council
For Researchers
Family Support
Family Resources
Early Outreach
Family Emergency Fund
Open Arms Meal Program
Counseling
Bereavement
Webinars
Printable Resources
New Patient Form
Formulario de Nuevo Paciente
News & Events
Our Events
Calendar
Blog
Newsletters
Get Involved
Volunteer Opportunities
Host a Fundraiser
Childhood Cancer Awareness Month
CURE Store
Ways To Give
Ways To Give
Donate Now
Give Monthly
Donate
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